Quality improvement project eliminates falls in recovery area of high volume endoscopy unit.

BACKGROUND: The authors' high-volume gastrointestinal endoscopy unit developed an infrastructure to track complications associated with endoscopic procedures in January of 2008. A result of this effort was the identification of a surprising number of patient falls in their recovery area. In response to this finding, the authors created and implemented a quality improvement project to eliminate patient falls in the endoscopy recovery area. METHODS: The authors analysed each patient fall to try to identify the root cause in each case, and found that most falls occurred in patients of advanced age or who ambulated with an assistive device and fell while changing clothes in the bathroom unaccompanied. The authors initiated a quality improvement project to identify patients at risk of falling and to make changes in the recovery room process to minimise their risk of falling. Any patient identified as a fall risk would then be accompanied to the bathroom to change by one of the allied health staff, and they would leave the recovery area in a wheelchair. The authors used descriptive statistics to analyse age, gender, use of an assistive ambulatory device and total number of endoscopic procedures. The authors used the Fisher exact test to compare the proportion of procedures that were complicated by patient falls before and after the quality improvement intervention. RESULTS: In 2008, the authors completed 38370 sedated endoscopic procedures and had eight patient falls (0.02%). Three patients were female, and the mean age was 67 (range 40-96). Five of the eight patients who fell were over the age of 70 and/or used an assistive device for ambulation. All patients sustained injuries that required additional medical attention. The authors' fall prevention initiative started on 23 January 2009. From 23 January 2009 to 23 January 2010, the unit completed 42845 sedated endoscopic procedures and had no patient falls in the endoscopic unit (p=0.002). CONCLUSIONS: These data demonstrate that a simple, low-cost intervention in a high-volume endoscopy centre can completely eliminate patient falls.

A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.

OBJECTIVES: Our institution has had problems with mislabeling of tissue specimens in our gastrointestinal and colorectal surgery endoscopy units. Most labeling errors have been due to either the wrong patient label or no label being affixed to a specimen bottle. As a result, an initiative was created to reduce the number of specimen-labeling errors. This initiative involved the application of radiofrequency identification (RFID) technology to specimen bottles, moving to a paperless pathology requisition system and confirmation of the correct site and correct patient by both the endoscopy nursing staff and the endoscopist for each specimen bottle. METHODS: We reviewed the number of specimen-labeling errors from our endoscopy unit for the first 3 months of 2007, before the implementation of the initiative, and for the first 3 months of 2008, 6 months after the initiation of RFID specimen labeling with paperless requisition and two-provider confirmation of correct site, correct patient specimen labeling. The RFID system we used was an off-the-shelf 3M (St. Paul, MN) Library Sciences RFID system modified and installed for our purposes. Specimen-labeling errors were categorized as Class 1 (only typographical with no potential clinical consequences), Class 2 (minor error, unlikely to have clinical consequences) or Class 3 (significant error that has the potential to detrimentally impact patient care). The Fischer's exact test was used to compare the rate of specimen-bottle labeling errors before and after the initiation of this new system. RESULTS: In the first 3 months of 2007, our endoscopy unit sent 8,231 specimen bottles to our pathology laboratory for evaluation; 8,539 bottles were sent in the first 3 months of 2008. There were 646 (7.85%) Class 1 errors in the first quarter of 2007 and 35 (0.41%) in the first quarter of 2008 (P<0.001). There were 112 (1.36%) Class 2 errors in the first quarter of 2007 and 10 (0.12%) in the first quarter of 2008 (P<0.001). Finally, in the first quarter of 2007 there were seven (0.09%) Class 3 errors and in the first quarter of 2008, there were two (0.02%) Class 3 errors. However, with the new system in place, both Class 3 errors in the first quarter of 2008 were recognized and corrected before the processing of the specimens in the pathology laboratory (P=0.001). CONCLUSIONS: These data confirm that the initiation of a new specimen-labeling system that uses RFID technology, a paperless requisition process, and confirmation of the correct site and correct patient by two health-care providers significantly decreased specimen-labeling errors at every level in a high-volume endoscopy center.